E-Waste Collection Order Form

Waste Collection Order Form

Please fill out the form to schedule your waste collection.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address for Collection

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Waste to Collect

ComputersTelevisionsPrintersCardboardPlasticOther
Weight (approximatet)
Preferred Collection Date

MonthDayYear
Date
Pictures *

Cancelof
Should be Empty: